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Three Medicare Changes Happening in 2021

After an eventful year, the Center for Medicare & Medicaid Services (CMS) is continuing to keep physicians on their toes. While annual Medicare changes can always be expected, 2021 has a host of unique changes related to our ongoing health emergency.

But luckily, you don’t have to sort through all these changes on your own. To get a full scope of the significant changes coming to Medicare coverage in 2021, watch our latest Town Hall webinar with Medicare compliance expert Nancy Beckley and Clinicient co-founder Jerry Henderson, PT. In our webinar, they’ve covered everything from the new rules and codes around telehealth and communication technology-based services (CTBS) to the latest updates on the Therapy Threshold (formerly known as the Therapy Cap).

Here are three highlights from the Town Hall on what changes to expect from Medicare this year.

Physician Fee Schedule Changes

It wouldn’t be a CMS update without a little bit of confusion and last-minute changes. This year, the Medicare Physician Fee Schedule (MPFS) experienced an adjustment in the final hours before 2021.

As Jerry and Nancy explained, the initial MPFS conversion factor for 2021 was supposed to change from $36.0986 in 2020 to $32.4085 in 2021. This would have caused a significant 9% cut in Medicare payments for practices that were already struggling with the ongoing public health emergency (PHE).

But luckily, an updated Final Rule was released just days before the new year. This new Final Rule adjusted the conversion factor slightly, from $32.4085 to $34.8931. The reason behind the adjustment was due to a three-year moratorium on payments for code G2211 (see pg. 1766), which freed up nearly $3 billion in funding. The G2211 moratorium primarily affects primary care and other specialists treating prolonged health needs but won’t be a major concern for outpatient rehab therapists.

While the decrease in Medicare payments is still a concern for physicians, the last-minute adjustment is a welcome improvement. And the MPFS conversion factor will have ripple effects across PT, OT, and SLP treatment codes (see image below for a rough estimate of price adjustments*). To determine how the new MPFS may impact your practice financially, refer to the MPFS Calculator provided by CMS (latest update: 1/29/2021) or the APTA calculator for members.

A graph of net effect* for PT, OT, and Speech treatment and eval codes after the MPFS adjustment.
*Rough estimates only; does not consider the following assumptions: sequestration, MPPR, geographic adjustments, and MIPS adjustments.

Using Assistants in Maintenance Programs and the Assistant Modifier

Remember the Jimmo Settlement from 2013? In the 2021 Final Rule, CMS finalized an interim proposal related to the Jimmo Settlement on maintenance therapy and utilizing assistants for medically necessary qualified services. The proposal states (see pg. 122 of the Federal Register PDF):

“As a means of increasing the availability of needed healthcare services during the PHE for COVID-19, we amended our therapy policy on an interim basis […] to allow PTs and OTs that have established a therapy maintenance program for a patient to assign a PTA or OTA to furnish the maintenance therapy services when clinically appropriate.”  

During the webinar, Nancy cautioned everyone to understand the full scope of maintenance therapy and associated CMS guidelines around approved maintenance programs. Jerry recommended our medical necessity checklist for Medicare services as a helpful resource.

Additionally, the Assistant Modifier (CQ and CO) is a year closer to its required-by date. We’ve talked about the Assistant Modifier in the past, but here’s a short recap:

In 2019, CMS allowed therapists to voluntarily report when using an assistant for a service. But in 2020 and 2021, reporting CQ and CO codes is required by CMS for any service “furnished in whole or in part by PTAs and OTAs […] on the claim line of the service alongside the respective GP or GO therapy modifier.” Beginning January 1, 2022, any service containing an Assistant Modifier will have a 15% fee schedule deduction. Qualified services include any in which the assistant performs more than 10% of a service.  

To help your organization prepare for the change, Nancy suggests creating a standard protocol for therapy assistants and sticking to it. The CMS calculator mentioned previously can help you determine the impact of the 15% reduction on Medicare payments to prepare for the change financially.

Updated Advance Beneficiary Notice of Noncoverage (ABN) Form

The ABN form isn’t new—it has been around since 2013—but it is getting an update. While the form itself has only had a date change, there are now additional guidelines in effect January 1, 2021, for the ABN form around people who are dually enrolled in both Medicare and Medicaid.

For practices that need to issue an ABN form for qualified patients, the new guidelines require practices to adjust the form themselves. Nancy has been encouraging practices to make their own form in a Word document, make the required adjustments, and save the form for any future patients that may qualify.

The changes that need to be made are located under G. when checking Option 1. Practices will need to strikethrough a sentence about Medicare payments (see image below) before submitting the claim for dually-enrolled patients.

A screenshot showing the adjustments needed for the "new" ABN form in 2021.
You can access all the PowerPoint slides from our Town Hall when watching the recording.

Luckily for Insight users, we’ve created a pre-filled ABN 2021 template you can use for qualified patients directly in our system. Once the form is completed, it’ll be automatically saved as an attachment to the patient’s case.

Learn more about Medicare changes in our Town Hall webinar

These are just three of the many topics covered in our first Town Hall of the year, so be sure to watch the whole webinar to catch all the tips and changes shared by Jerry Henderson, PT, and Nancy Beckley. And stay tuned for our next Town Hall, where we’ll continue to cover the latest news in the industry and offer a forum for therapists and their teams to discuss trends and share tips.

IMPORTANT NOTICE: The information provided herein is intended to be general in nature. It is not offered as legal or insurance-related advice and is not a complete description, or meant, or intended, to replace or be interpreted as specific, of Medicare requirements. Although every effort has been made to ensure the content herein is correct, we assume no responsibility for its accuracy. Contact the Department of Health & Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) for more information.

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